Common use of Reasons for Disenrollment Clause in Contracts

Reasons for Disenrollment. EOHHS will disenroll members from a Health Plan for any of the following reasons: • Loss of Medicaid eligibility or medically needy • Loss of program eligibility • Transfer to another Health Plan • Death • Relocation out-of-State • Adjudicative actions • Change of eligibility status • Placement in a nursing facility for more than thirty (30) consecutive days, for Rhody Health Partners and Expansion members only • Placement in Xxxxxxx Xxxxxx, Xxxxxxx or an out-of- state hospital • Eligibility determination error • Just cause (as determined by EOHHS on an individual basis) • The enrollees service needs (e.g. cesarean section and a tubal ligation) are not available within the network and that the enrollee’s primary care provider or another provider determines that not receiving the services will subject the enrollee to unnecessary risk. • Other reasons for disenrollment include but are not limited to, poor quality of care, lack of access to providers experienced in dealing with the enrollee’s health needs. A member has the right to disenroll with cause from the Contractor at any time. A member may disenroll from the plan either in writing or orally. A member may request disenrollment without cause during the ninety (90) days following the date of the recipient’s initial enrollment with the Contractor. A member may request disenrollment without cause at least once every twelve (12) months thereafter. A member may request disenrollment under 42 CFR 438.56(d)(2), if the Contractor does not cover the service the member seeks, because of moral or religious grounds. Pursuant to 42 CFR 438.56(d)(2)(i), a member may request disenrollment, upon relocation out-of- state. A member may request disenrollment upon automatic reenrollment under 42 CFR 438.56(g)xiii if the temporary loss of Medicaid eligibility has caused the recipient to miss the annual disenrollment opportunity. A member may request disenrollment under 42 CFR 438.56(d)(2), if the member needs services to be performed at the same time and not all services are available within the network. The member’s PCP or another provider must determine that receiving the services separately would subject the member to unnecessary risk. A member may request to disenroll without cause when EOHHS imposes, upon the Contractor, the intermediate sanctions identified in 42 CFR 438.702(a)(4)xiv. The Contractor cannot refuse to cover services because of moral or religious objections. EOHHS reserves the right to disenroll members whom the Contractor is unable to contact within contractual timeframes or members for whom the Contractor cannot produce evidence of services provided within contractual timeframes, as set forth herein. In accordance with 42 CFR 438.56(b)(2)xv, the Contractor may not request disenrollment of a member because of an adverse change in the member’s health status, or because of the member’s utilization of medical services, diminished mental capacity, or uncooperative or disruptive behavior resulting from the member’s special needs (except when the member’s continued enrollment in the Health Plan seriously impairs the Health Plan’s ability to furnish services to either the particular member or other members). The Contractor may request in writing that a member be disenrolled for the foregoing exception. All disenrollment’s are subject to approval by EOHHS, and the Contractor will submit written disenrollment policies and procedures to EOHHS for approval.

Reasons for Disenrollment. EOHHS will The State shall disenroll members from a Health Dental Plan for any of the following reasons: • Loss of Medicaid eligibility or medically needy • Loss of program eligibility • Transfer to For members who opt for another Health Plan Medical Assistance managed care option • Death • Relocation out-of-State • Adjudicative actions • Change of eligibility status • Placement in a nursing facility for more than thirty (30) consecutive daysXxxxxxx Xxxxxx Hospital, for Rhody Health Partners and Expansion members only • Placement Cranston RI or placement in Xxxxxxx XxxxxxPediatric Center, Xxxxxxx Providence RI or placement in an out-of- state hospital • Eligibility determination error • Just cause (as determined by EOHHS the State on an individual basis) • The enrollees service needs (e.g. cesarean section and a tubal ligation) are not available within the network and that the enrollee’s primary care provider or another provider determines that not receiving the services will subject the enrollee to unnecessary risk. • Other reasons for disenrollment include but are not limited to, : poor quality of care, lack of access to providers experienced in dealing with the enrolleemember’s health needs. A member has the right to disenroll with cause from the Contractor at any time. A member may disenroll from the plan either in writing or orally. A member may request disenrollment without cause during the ninety (90) days following the date of the recipient’s initial enrollment with the Contractor. A member may request disenrollment without cause at least once every twelve (12) months thereafter. A member may request disenrollment under 42 CFR 438.56(d)(2), if the Contractor does not cover the service the member seeks, because of moral or religious grounds. Pursuant to 42 CFR 438.56(d)(2)(i), a member may request disenrollment, upon relocation out-of- state. A member may request disenrollment upon automatic reenrollment under 42 CFR 438.56(g)xiii if the temporary loss of Medicaid eligibility has caused the recipient to miss the annual disenrollment opportunity. A member may request disenrollment under 42 CFR 438.56(d)(2), if the member needs services to be performed at the same time and not all services are available within the network. The member’s PCP or another provider must determine that receiving the services separately would subject the member to unnecessary risk. A member may request to disenroll without cause when EOHHS imposes, upon the Contractor, the intermediate sanctions identified in 42 CFR 438.702(a)(4)xivDental Plan. The Contractor cannot refuse to cover services because of moral or religious objections. EOHHS reserves the right to disenroll members whom the Contractor is unable to contact within contractual timeframes or members for whom the Contractor cannot produce evidence of services provided within contractual timeframes, as set forth herein. The contract specifies that a recipient (or his/her representative) must request disenrollment by submitting an oral or written request to the State (or its agent) or the MCE, if the State allows the MCE to process disenrollment requests, per CMS contract rule 42 § C.F.R. 438.56(d)(1)(ii). The contract allows enrollees to request disenrollment if: the enrollee needs related services to be performed at the same time; not all related services are available within the provider network; and the enrollee’s primary care provider or another provider determines that receiving the services separately would subject the enrollee to unnecessary risk, per CMS contract rule 42 CFR 438.56(d)(2)(iii). In accordance with 42 CFR 438.56(b)(2)xv§ C.F.R. 438.56(b)(2), the Contractor may not request disenrollment of a member because of an adverse change in the member’s health status, or because of the member’s utilization of medical dental services, diminished mental capacity, or uncooperative or disruptive behavior resulting from the member’s special needs (except when the member’s continued enrollment in the Health Dental Plan seriously impairs the Health Dental Plan’s ability to furnish services to either the particular member or other members). The Contractor may request in writing that a member be disenrolled for the foregoing exception. All disenrollment’s are disenrollment is subject to approval by EOHHSthe State, and the Contractor will shall submit written disenrollment policies and procedures to EOHHS the State for approval.. A member is permitted to disenroll without cause during the 90 days following the effective date of the individual’s initial enrollment with the Dental Plan and when the State imposes the intermediate sanction in 42 § C.F.R. 438.702(a)(3)

Reasons for Disenrollment. EOHHS will disenroll members from a Health Plan for any of the following reasons: • Loss of Medicaid eligibility or medically needy • Loss of program eligibility • Transfer to another Health Plan • Death • Relocation out-of-State • Adjudicative actions • Change of eligibility status • Placement in a nursing facility for more than thirty (30) consecutive days, for Rhody Health Partners and Expansion members only • Placement in Xxxxxxx Xxxxxx, Xxxxxxx or an out-of- state hospital • Eligibility determination error • Just cause (as determined by EOHHS on an individual basis) • The enrollees service needs (e.g. cesarean section and a tubal ligation) are not available within the network and that the enrollee’s primary care provider or another provider determines that not receiving the services will subject the enrollee to unnecessary risk. • Other reasons for disenrollment include but are not limited to, poor quality of care, lack of access to providers experienced in dealing with the enrollee’s health needs. A member has the right to disenroll with cause from the Contractor at any time. A member may disenroll from the plan either in writing or orally. A member may request disenrollment without cause during the ninety (90) days following the date of the recipient’s initial enrollment with the Contractor. A member may request disenrollment without cause at least once every twelve (12) months thereafter. A member may request disenrollment under 42 CFR 438.56(d)(2), if the Contractor does not cover the service the member seeks, because of moral or religious grounds. Pursuant to 42 CFR 438.56(d)(2)(i), a member may request disenrollment, upon relocation out-of- state. A member may request disenrollment upon automatic reenrollment under 42 CFR 438.56(g)xiii 438.56(g) xiii if the temporary loss of Medicaid eligibility has caused the recipient to miss the annual disenrollment opportunity. A member may request disenrollment under 42 CFR 438.56(d)(2), if the member needs services to be performed at the same time and not all services are available within the network. The member’s PCP or another provider must determine that receiving the services separately would subject the member to unnecessary risk. A member may request to disenroll without cause when EOHHS imposes, upon the Contractor, the intermediate sanctions identified in 42 CFR 438.702(a)(4)xiv438.702(a)(4) xiv. The Contractor cannot refuse to cover services because of moral or religious objections. EOHHS reserves the right to disenroll members whom the Contractor is unable to contact within contractual timeframes or members for whom the Contractor cannot produce evidence of services provided within contractual timeframes, as set forth herein. In accordance with 42 CFR 438.56(b)(2)xv438.56(b)(2) xv, the Contractor may not request disenrollment of a member because of an adverse change in the member’s health status, or because of the member’s utilization of medical services, diminished mental capacity, or uncooperative or disruptive behavior resulting from the member’s special needs (except when the member’s continued enrollment in the Health Plan seriously impairs the Health Plan’s ability to furnish services to either the particular member or other members). The Contractor may request in writing that a member be disenrolled for the foregoing exception. All disenrollment’s are subject to approval by EOHHS, and the Contractor will submit written disenrollment policies and procedures to EOHHS for approval.

Reasons for Disenrollment. EOHHS will The State shall disenroll members from a Health Dental Plan for any of the following reasons: • Loss of Medicaid eligibility or medically needy • Loss of program eligibility • Transfer to For members who opt for another Health Plan Medical Assistance managed care option • Death • Relocation out-of-State • Adjudicative actions • Change of eligibility status • Placement in a nursing facility for more than thirty (30) consecutive daysXxxxxxx Xxxxxx Hospital, for Rhody Health Partners and Expansion members only • Placement Cranston RI or placement in Xxxxxxx XxxxxxPediatric Center, Xxxxxxx Providence RI or placement in an out-of- state hospital • Eligibility determination error • Just cause (as determined by EOHHS the State on an individual basis) • The enrollees service needs (e.g. cesarean section and a tubal ligation) are not available within the network and that the enrollee’s primary care provider or another provider determines that not receiving the services will subject the enrollee to unnecessary risk. • Other reasons for disenrollment include but are not limited to, : poor quality of care, lack of access to providers experienced in dealing with the enrolleemember’s health needs. A member has the right to disenroll with cause from the Contractor at any time. A member may disenroll from the plan either in writing or orally. A member may request disenrollment without cause during the ninety (90) days following the date of the recipient’s initial enrollment with the Contractor. A member may request disenrollment without cause at least once every twelve (12) months thereafter. A member may request disenrollment under 42 CFR 438.56(d)(2), if the Contractor does not cover the service the member seeks, because of moral or religious grounds. Pursuant to 42 CFR 438.56(d)(2)(i), a member may request disenrollment, upon relocation out-of- state. A member may request disenrollment upon automatic reenrollment under 42 CFR 438.56(g)xiii if the temporary loss of Medicaid eligibility has caused the recipient to miss the annual disenrollment opportunity. A member may request disenrollment under 42 CFR 438.56(d)(2), if the member needs services to be performed at the same time and not all services are available within the network. The member’s PCP or another provider must determine that receiving the services separately would subject the member to unnecessary risk. A member may request to disenroll without cause when EOHHS imposes, upon the Contractor, the intermediate sanctions identified in 42 CFR 438.702(a)(4)xivDental Plan. The Contractor cannot refuse to cover services because of moral or religious objections. EOHHS reserves the right to disenroll members whom the Contractor is unable to contact within contractual timeframes or members for whom the Contractor cannot produce evidence of services provided within contractual timeframes, as set forth herein. The contract specifies that a recipient (or his/her representative) must request disenrollment by submitting an oral or written request to the State (or its agent) or the MCE, if the State allows the MCE to process disenrollment requests, per CMS contract rule 42 CFR 438.56(d)(1)(ii). The contract allows enrollees to request disenrollment if: the enrollee needs related services to be performed at the same time; not all related services are available within the provider network; and the enrollee’s primary care provider or another provider determines that receiving the services separately would subject the enrollee to unnecessary risk, per CMS contract rule 42 CFR 438.56(d)(2)(iii). In accordance with 42 CFR 438.56(b)(2)xv438.56(b)(2), the Contractor may not request disenrollment of a member because of an adverse change in the member’s health status, or because of the member’s utilization of medical dental services, diminished mental capacity, or uncooperative or disruptive behavior resulting from the member’s special needs (except when the member’s continued enrollment in the Health Dental Plan seriously impairs the Health Dental Plan’s ability to furnish services to either the particular member or other members). The Contractor may request in writing that a member be disenrolled for the foregoing exception. All disenrollment’s are disenrollment is subject to approval by EOHHSthe State, and the Contractor will shall submit written disenrollment policies and procedures to EOHHS the State for approval. A member is permitted to disenroll without cause during the 90 days following the effective date of the individual’s initial enrollment with the Dental Plan and when the State imposes the intermediate sanction in 42 CFR 438.702(a) (3).

Reasons for Disenrollment. EOHHS will The State shall disenroll members from a Health Dental Plan for any of the following reasons: • Loss of Medicaid eligibility or medically needy • Loss of program eligibility • Transfer to For members who opt for another Health Plan Medical Assistance managed care option • Death • Relocation out-of-State • Adjudicative actions • Change of eligibility status • Placement in a nursing facility for more than thirty (30) consecutive daysXxxxxxx Xxxxxx Xxxpital, for Rhody Health Partners and Expansion members only • Placement Cranston RI or placement in Xxxxxxx XxxxxxPediatric Center, Xxxxxxx Providence RI or placement in an out-of- state hospital • Eligibility determination error • Just cause (as determined by EOHHS the State on an individual basis) • The enrollees service needs (e.g. cesarean section and a tubal ligation) are not available within the network and that the enrollee’s primary care provider or another provider determines that not receiving the services will subject the enrollee to unnecessary risk. • Other reasons for disenrollment include but are not limited to, : poor quality of care, lack of access to providers experienced in dealing with the enrolleemember’s health needs. A member has the right to disenroll with cause from the Contractor at any time. A member may disenroll from the plan either in writing or orally. A member may request disenrollment without cause during the ninety (90) days following the date of the recipient’s initial enrollment with the Contractor. A member may request disenrollment without cause at least once every twelve (12) months thereafter. A member may request disenrollment under 42 CFR 438.56(d)(2), if the Contractor does not cover the service the member seeks, because of moral or religious grounds. Pursuant to 42 CFR 438.56(d)(2)(i), a member may request disenrollment, upon relocation out-of- state. A member may request disenrollment upon automatic reenrollment under 42 CFR 438.56(g)xiii if the temporary loss of Medicaid eligibility has caused the recipient to miss the annual disenrollment opportunity. A member may request disenrollment under 42 CFR 438.56(d)(2), if the member needs services to be performed at the same time and not all services are available within the network. The member’s PCP or another provider must determine that receiving the services separately would subject the member to unnecessary risk. A member may request to disenroll without cause when EOHHS imposes, upon the Contractor, the intermediate sanctions identified in 42 CFR 438.702(a)(4)xivDental Plan. The Contractor cannot refuse to cover services because of moral or religious objections. EOHHS reserves the right to disenroll members whom the Contractor is unable to contact within contractual timeframes or members for whom the Contractor cannot produce evidence of services provided within contractual timeframes, as set forth herein. The contract specifies that a recipient (or his/her representative) must request disenrollment by submitting an oral or written request to the State (or its agent) or the MCE, if the State allows the MCE to process disenrollment requests, per CMS contract rule 42 § C.F.R. 438.56(d)(1)(ii). The contract allows enrollees to request disenrollment if: the enrollee needs related services to be performed at the same time; not all related services are available within the provider network; and the enrollee’s primary care provider or another provider determines that receiving the services separately would subject the enrollee to unnecessary risk, per CMS contract rule 42 CFR 438.56(d)(2)(iii). In accordance with 42 CFR 438.56(b)(2)xv§ C.F.R. 438.56(b)(2), the Contractor may not request disenrollment of a member because of an adverse change in the member’s health status, or because of the member’s utilization of medical dental services, diminished mental capacity, or uncooperative or disruptive behavior resulting from the member’s special needs (except when the member’s continued enrollment in the Health Dental Plan seriously impairs the Health Dental Plan’s ability to furnish services to either the particular member or other members). The Contractor may request in writing that a member be disenrolled for the foregoing exception. All disenrollment’s are disenrollment is subject to approval by EOHHSthe State, and the Contractor will shall submit written disenrollment policies and procedures to EOHHS the State for approval.. A member is permitted to disenroll without cause during the 90 days following the effective date of the individual’s initial enrollment with the Dental Plan and when the State imposes the intermediate sanction in 42 § C.F.R. 438.702(a)(3)